Method and apparatus for providing proportional positive airway pressure to treat congestive heart failure

ABSTRACT

A system including methods and apparatus for treatment of Congestive Heart Failure. The system involves applying separate and independent gains to flow rates of pressurized gas delivered to a patient during inspiratory and expiratory phases of a respiratory cycle to deliver the pressurized gas in proportion to the respective gains during inspiration and expiration. A base pressure may be applied in addition to the gain-modified pressures and an elevated pressure profile may be employed to assist or control inspiration. The system may be fully automated responsive to feedback provided by a flow sensor that determines the estimated patient flow rate. A leak computer can be included to instantaneously calculate gas leakage from the system. The system may be utilized in connection with conventional continuous positive airway pressure (bi-level PAP) equipment to effect various beneficial treatment applications.

This is a continuation-in-part application of application Ser. No. 08/253,496 filed Jun. 3, 1994, now U.S. Pat. No. 5,535,738.

FIELD OF THE INVENTION

The present invention relates generally to methods and apparatus for treating breathing disorders and, more particularly, to methods and apparatus for administering proportional positive airway pressure to provide continuously variable pressure in response to patient breathing for the treatment of Obstructive Sleep Apnea Syndrome, Chronic Obstructive Pulmonary Disease and other breathing disorders. The administering of proportional positive airway pressure can also be applied to the treatment of Congestive Heart Failure.

BACKGROUND OF THE INVENTION

During Obstructive Sleep Apnea Syndrome (OSAS), the airway is prone to narrowing and/or collapse while the patient sleeps. Continuous positive airway pressure (CPAP) therapy seeks to avoid this narrowing by supplying pressure to splint the airway open. With CPAP this splinting pressure is constant and is optimized during a sleep study to be sufficient in magnitude to prevent narrowing of the airway. Providing a constant splinting pressure (i.e., CPAP) is a simple solution to the problem posed by the collapsing airway. However, this approach exposes the patient to pressures that are higher than the pressures needed to support the airway for most of the breathing cycle.

During inspiration, the pressure created within the lungs is lower than the pressure at the nose. This pressure difference drives the flow of air into the lungs. This pressure difference creates a pressure gradient in the airway connecting the lungs with the nose. That is to say, the nose is typically at ambient pressure while the lungs and airway of the patient are at sub-ambient or negative pressures. This negative pressure acts upon the airway and contributes to its collapse. CPAP levels are typically set to raise the pressure level in the entire respiratory system to the level required to both eliminate the sub-ambient pressures generated by inspiration and overcome any mechanical collapsing forces that result from the structure of the airway tissues, muscle tone, and body position. The inspiratory pressures (i.e., inspiratory positive airway pressure or "IPAP," in bi-level positive airway pressure (bi-level PAP) systems are set in a similar manner.

During exhalation, a positive pressure gradient exists between the interior of the lungs and the exterior of the body. This positive pressure gradient helps to support the airway during exhalation. At the end of exhalation the pressure gradient is essentially zero (flow is likewise zero and the airway is unaffected by respiratory efforts). Any collapse of the airway at the end of exhalation is purely a function of the structure of the airway tissues, muscle tone, and body position. Bi-level devices seek to supply the expiratory pressure required to support the airway at the end of exhalation.

It should be noted that over the course of a breathing cycle the pressure gradients between the lungs and the exterior of the body are not constant. The inspiratory pressure gradient falls from zero at the start of inspiration to a peak negative value and then rises back to zero at the end of inspiration. The expiratory pressure gradient rises from zero at the start of exhalation to a peak value and then falls back to zero as exhalation ends. Because the pressure gradient varies over the breathing cycle, the pressure necessary to overcome airway collapse should ideally vary over the breathing cycle.

CPAP therapy ignores these variations in pressure requirements and provides therapy at one pressure level. CPAP is rather crude and offers far from optimal therapy since the CPAP pressure is based solely on a worst-case treatment parameter, i.e., the peak pressure requirements during inspiration.

Representing an advancement over CPAP, bi-level positive airway pressure (bi-level PAP) therapies seek to take advantage of the different pressure requirements to lower the pressure during exhalation. Nevertheless, bi-level therapies also fail to afford optimal treatment since the inspiratory positive airway pressure (IPAP) of bi-level PAP applied during inspiration is again based on the patient's peak needs encountered during inspiration and the expiratory position airway pressure (EPAP) of bi-level PAP delivered during expiration is related solely to the support needs at the end of exhalation.

In addition to OSAS, positive airway pressure therapy has been applied in the treatment of other breathing disorders such as Chronic Obstructive Pulmonary Disorder (COPD). COPD can be treated with bi-level PAP therapy. One of the problems with this mode of treatment, however, is that the patient has difficulty stopping inspiratory flow. This phenomenon arises from the disparity between applied IPAP pressure and the pressure needed to overcome the patient's respiratory resistance at the end of inspiration. As the former pressure typically exceeds the latter, the "surplus" IPAP pressure at the end of inspiration leads to uncomfortable and potentially harmful hyperinflation of the patient lungs.

Conversely, in order to begin inspiratory flow, a COPD patient must reduce the pressure inside his lungs to a pressure that is less than the ambient pressure at the inlet of his respiratory system. Due to the condition commonly known as "Auto-PEEP," the pressure in the patient's lungs is typically above ambient pressure at the end of exhalation. The patient's breathing muscles thus must perform additional work to expand the lungs and thereby reduce lung pressure below ambient before flow into the lungs can occur. Auto-PEEP is typically treated with a form of resistive counter pressure known as PEEP (positive end expiratory pressure). PEEP is set at a level just below the patient's Auto-PEEP level, thereby reducing the amount of breathing work required to initiate inspiratory flow.

With conventional treatments such as pressure support, CPAP or bi-level therapy, PEEP is achieved by applying the same pressure over the entire phase of expiration, e.g., the EPAP phase of bi-level PAP therapy. It should be noted at this juncture that EPAP is not synonymous with PEEP. EPAP indicates a constant pressure delivered to the patient throughout exhalation while PEEP indicates positive end expiratory pressure. By definition, the PEEP pressure is only required at the end of exhalation. As such, the administration of EPAP throughout the expiratory cycle to assure that satisfactory PEEP is maintained undesirably contributes to the breathing work that a patient must perform during exhalation.

In addition to CPAP and bi-level PAP, other systems have been proposed for clinical research and/or therapeutic application (including treatment of OSAS, COPD and other breathing disorders) that offer an assortment of methods and apparatus by means of which a subject's respiratory efforts may be induced, superseded, assisted and/or resisted. Some of these systems perform their prescribed functions responsive to one or more parameters associated with a subject's respiratory activity including, but not limited to, inspiratory and/or expiratory flow, inspiratory and/or expiratory pressure, tidal volume and symptoms indicative of airway obstruction, e.g., snoring sounds. Some achieve their objectives transthoracically while others deliver air at positive or negative pressure directly to the subject's airway.

An early example of such a system, commonly referred to as an "iron lung," is disclosed in a publication entitled "Mechanical Assistance to Respiration in Emphysema, Results with a Patient-Controlled Servorespirator," authored by James R. Harries, M. D. and John M. Tyler, M.D., published in the American Journal of Medicine, Vol. 36, pp. 68-78, January 1964. The iron lung proposed in that publication is a respirator designed to apply and remove transthoracic pressure to and from the exterior surface of the body of a subject who sits in a large pressurizable chamber in order to assist the patient's respiratory efforts (i.e., the iron lung applies negative pressure during inspiration and either ambient or positive pressure during expiration). Sophisticated for its day, the apparatus continually controlled the internal chamber pressure in response to the patient's spontaneous respiration, specifically in response to detected respiratory flow or volume. Indeed, a signal obtained from a strain gauge pneumograph fastened around the patient's chest was electrically separated into three components: one proportional to volume, another to inspiratory flow and a third to expiratory flow. Each component was assigned a separate gain control. The component signals are then recombined to control the pressure in the chamber by means of an electrically driven variable valve situated between a blower and the chamber.

Although effective for their intended purposes, this and other iron lungs have generally fallen into disfavor because of their bulk, inconvenience, cost and limited application. That is to say, because of their size and cost such equipment is purchased and maintained essentially exclusively by medical facilities such as hospitals and clinics. Further, iron lungs do not lend themselves to treatment of OSAS and related disorders where comfort and unobtrusiveness are critical for patient compliance and treatment efficacy. This is because negative pressure applied during inspiration compounds the factors that operate to collapse the airway during an inspiratory phase.

An essay entitled "An Apparatus for Altering the Mechanical Load of the Respiratory System," authored by M. Younes, D. Bilan, D. Jung and H. Krokes, and published in 1987 by the American Physiological Society, pp. 2491-2499, discloses a system for loading and unloading of a subject's respiratory efforts to effect various respiratory responses. The system may load or unload during inspiration, expiration, or both, to assist or resist a subject's spontaneous respiratory activity. The system may apply a continuous positive or negative pressure directly to the subject's airway and loading or unloading occurs via a command signal generated by detected respiratory flow, volume, applied voltage, an external function, or other source.

A drawback to this system, however, is that but a single resistive gain may be chosen for resistive loading or unloading. This single gain is applied to a "half-wave" of the respiratory cycle (either inspiration or expiration) or the "full-wave" thereof (both inspiration and expiration). In other words, under full-wave respiratory loading or unloading, a single chosen gain value is employed during both inspiration and expiration. Thus, a gain that may produce favorable results in regard to reducing breathing work during inspiration, for example, may cause less than desirable or even detrimental consequences during expiration. The converse is true for a gain selected specifically for optimizing expiratory work reduction.

In addition, the Younes et al. system operates as a closed, leak-proof system. Hence, to predict its ability to function in an open, leak-tolerant system would be problematic. As such, whether it may be adapted to OSAS treatment, which invariably involves some degree of known and unavoidable unknown system leakage, is suspect.

U.S. Pat. No. 5,107,830 to Younes essentially reiterates all of the "breathing assist" (unloading) disclosure that is covered in the Younes, et al. American Physiological Society publication discussed above.

In the system disclosed in U.S. Pat. No. 5,107,830, however, the adjustable pressure gain is only realized during inspiration because pressure output is set to zero during exhalation. Additionally, output pressure is calculated as a function of both detected patient inspiratory flow and volume. Furthermore, the system is applicable to COPD but not OSAS therapy.

An article entitled "A Device to Provide Respiratory-Mechanical Unloading," authored by Chi-sang Poon and Susan A. Ward and published in March 1987 in IEEE Transactions on Biomedical Engineering, Vol. BME-33, No. 3, pp. 361-365, is directed to an apparatus which functions somewhat similar to one mode of operation described in both Younes disclosures. That is, the Poon, et al. device may operate to unload a subject's breathing, but only during inspiration. Poon, et al. provide their inspiratory assistance by establishing a positive mouth pressure throughout inspiration in a constant proportion to instantaneous flow. The constant proportion is achieved by (1) selecting a desired gain for a detected positive mouth pressure signal, (2) calculating the ratio of the gain-modified mouth pressure signal over a detected signal reflecting instantaneous flow, (3) comparing the calculated ratio to a selected reference ratio to generate a valve motor control signal, and (4) using the valve motor control signal to operate a motor that drives a servo valve to control the positive pressure applied to the subject's airway. Thus, the apparatus output pressure is determined as a function of both detected pressure and flow. Further, the pressure must be output at a value sufficient to maintain a constant ratio of pressure to flow.

A publication entitled "Servo Respirator Constructed from a Positive-Pressure Ventilator," by John E. Remmers and Henry Gautier, which was published in August, 1976 in the Journal of Applied Physiology, Vol. 41, No. 2, pp. 252-255, describes a modified ventilator that may function as a "demand" respirator which generates transthoracic pressure proportional to phrenic efferent respiratory discharge. Phrenic efferent respiratory discharge is an indication of the outgoing brain signal to the phrenic nerve which controls diaphragm function. A phrenic efferent respiratory discharge signal causes the diaphragm to contract whereby the subject exerts an inspiratory effort. The phrenic efferent respiratory discharge serves as the apparatus command signal and is processed to produce a moving time average (MTA) and the subject's tracheal pressure serves as a negative feedback signal. Like the Poon et al. device, the Remmers et al. apparatus provides respiratory assistance only during inspiration.

An apparatus for automatically regulating the flow and pressure output of a respirator is disclosed in U.S. Pat. No. 3,961,627 to Ernst et al. Like the aforementioned Poon et al. device, however, the Ernst et al. apparatus relies upon an unduly complicated scheme dependent upon detected respiratory pressure and flow in calculating delivered output flow and pressure. More particularly, Ernst et al. propose regulating the delivered flow and pressure of a respiration gas in a respirator during the respiration cycle in which the actual flow and pressure of the respiration gas are measured via a measuring device arranged proximate a patient interface. The measured values are converted into electrical signals and the flow and pressure of the respiration gas are controlled during the inspiration and expiration portions of the respiration cycle via a valve arranged between a respiration gas source and the measuring device. The method for regulating the flow and pressure output comprises (1) measuring the actual flow of respiration gas proximate the patient, (2) measuring the actual pressure of respiration gas proximate the patient, (3) calculating nominal values of flow and pressure from preselected fixed values and the actual values, (4) comparing the actual values measured for the flow and pressure with the nominal values, and (5) obtaining from the comparison a control signal for modulating the valve and thereby regulating the flow and pressure of the respiration gas.

Additionally, apart from its utilization of two detected respiratory parameters (flow and pressure) and the complex manner in which these and other variables are reiteratively processed to produce apparatus flow and pressure output, the Ernst et al. system, although capable of delivering a base pressure equivalent to a patient's required end expiratory pressure, is nevertheless unable to deliver any pressure less than the base pressure. Consequently, the Ernst et al. apparatus requires the patient to perform more breathing work than is necessary to satisfy his respiratory needs, especially in the expiratory phase of a respiration cycle, thereby deleteriously affecting the patient's comfort and likelihood of continued compliance with the treatment.

An advantage exists therefore, for an uncomplicated system operable to deliver pressurized air to the airway of a patient and readily adaptable to the treatment of OSAS, COPD and other respiratory disorders. Such system should be capable of minimizing a patient's breathing work during both the inspiratory and expiratory phases of a respiratory cycle and operable to function in response to a single, easily and accurately detected respiratory parameter such as respiratory flow.

In addition to the treatment of breathing disorders, positive airway pressure therapy has been applied to the treatment of Congestive Heart Failure (CHF). In using CPAP on CHF, the effect of the CPAP is to raise the pressure in the chest cavity surrounding the heart. This has the impact of reducing the amount of pressure the heart has to pump against to move blood into the body. By reducing the pressure the heart works against, the work required of the heart is reduced. This allows the sick heart to rest and potentially to get better.

The pressure in the chest cavity is also impacted by respiration effort. With inspiration, the pressure in the chest is reduced (negative relative to resting pressure) due to inspiratory effort. This forces the heart to pump harder to move blood into the body. With expiration, the pressure in the chest is slightly increased (positive relative to resting pressure) due to the elastic properties of the chest. This allows the heart to decrease its efforts to pump blood. While CPAP can help the heart rest, it has negative aspects for the patient such as increased work of exhalation and discomfort from the pressure.

An advantage therefore exists for a positive airway pressure apparatus which reduces the mean pressure and work of exhalation while still providing the same level of rest to the heart.

SUMMARY OF THE INVENTION

The system of the present invention generally comprises a source of pressurized air, control means for regulating the pressure of air delivered to a patient, means for delivering pressurized air to the patient's airway and means operatively connected to the control means for detecting the magnitude of pressure gradients between the lungs and the exterior of the patient's body. So constructed, the PPAP apparatus continuously delivers pressure to the patient's airway minimally sufficient to prevent the collapse of the airway, which pressure may vary throughout the breathing cycle. The delivered pressure is the summation of the pressure necessary to prevent airway collapse in the absence of respiratory efforts (collapse due to airway structure, muscle tone, and body position), and the pressure necessary to overcome the collapsing or splinting effects of respiratory efforts.

According to a presently preferred embodiment of the invention, the apparatus (referred to as a "proportional positive airway pressure" or "PPAP" apparatus) comprises a pressure source such as a conventional CPAP/bi-level PAP blower (centrifugal blower with relatively steep pressure-flow relationship at any constant speed), a pressure control valve, a flow sensing element and a logic mechanism to receive flow information and control pressure output of the valve/blower tandem. The delivery means may include a large bore flexible patient tube and patient interface with an exhaust means (nasal mask, nasal seals, nasal prongs, mouthpiece, nasal/oral mask, trachea adapter, or endotracheal tube). The magnitude of the pressure gradients is detected by measuring patient flow using the flow sensing element (within the scope of the present invention, flow and respiratory pressure gradient are highly correlated). The pressure control system can be an open or a closed loop (feedback) control mechanism that may provide pressure to the patient in several alternative modes to be described hereinafter.

The PPAP system of the present invention provides airway pressure that is lower than pressures typically necessary to treat Obstructive Sleep Apnea Syndrome (OSAS), which is normally treated using conventional continuous positive airway pressure (PPAP) or bi-level positive airway pressure (bi-level PAP) therapy. With PPAP, the patient receives exhalation pressures lower than conventional bi-level PAP expiratory positive airway pressure (EPAP) levels and well below conventional CPAP levels. And, average pressure delivered during inspiration can be lower than conventional or bi-level PAP inspiratory positive airway pressure (IPAP) or CPAP levels, whereas peak PPAP pressure is roughly equivalent to conventional IPAP or CPAP levels. The PPAP pressure range (peak inspiratory pressure to minimum expiratory pressure) can be from about 2 to 20 cm H₂ O with typical values in the 8 to 14 cm H₂ O range (which is consistent with bi-level PAP therapy where significant comfort/compliance is found with peak inspiratory to minimum expiratory pressure differentials of 6 cm H₂ O or more). Complexity of titration using the apparatus of the instant invention is roughly equivalent to current bi-level PAP titration. In addition, the titration system may incorporate a feedback circuit to provide fully automated PPAP.

Similar to treatment of OSAS, PPAP may also deliver mean airway pressure that is lower than pressures typically necessary to treat Chronic Obstructive Pulmonary Disorder (COPD) using conventional bi-level PAP therapy with positive end expiratory pressure (PEEP) or proportional assist ventilation (PAV) with PEEP. That is, with PPAP, the patient receives exhalation pressures lower than conventional EPAP levels, average inspiration pressures lower than conventional IPAP, and peak PPAP pressure roughly equivalent to conventional IPAP pressures and conventional peak PAV levels. Hence, less of breathing work is required with PPAP than with conventional PAV or bi-level treatments of COPD or OSAS.

PPAP is a means of providing pressure to a patient via nasal, nasal/oral, oral, or trachea interface to treat OSAS, COPD and other breathing disorders. The pressure delivered to the patient is a function of the patient flow rate. The function can be described as follows:

    P.sub.delivered =P.sub.base +Gain*Flow

Where:

"P_(delivered) " is the pressure delivered to the patient interface.

"P_(base) " is the base line pressure (greater than or equal to zero and conceptually equal to EPAP).

"Flow" is the estimated patient flow.

"Gain" is the constant used to augment pressure based on the flow rate. The gain constant can further be refined to allow one constant for inspiration (positive flow) and a different constant for exhalation (negative flow).

Further, the PPAP apparatus of the present invention permits independent gains to be chosen for inspiration and expiration, thus:

    P.sub.inhalation =P.sub.base +Gain.sub.Insp *Flow

and

    P.sub.exhalation =P.sub.base +Gain.sub.Exp *Flow

Where:

"Gain_(Insp) " is the constant used during inspiration (positive flow) to boost pressure based on the flow rate.

"Gain_(Exp) " is the constant used during exhalation (negative flow) to reduce pressure based on the flow rate.

The gain typically selected has a range of about 0 to 10 cm H₂ O/liter/second for inspiration. The gain chosen for exhalation is normally lower than the inspiratory gain (e.g., values in the range of about 0 to 4 cm H₂ O/liter/second), although higher gain values may be chosen for inspiration and/or expiration, if such is desired or necessary.

Applying a flow signal derived from a normal respiratory pattern will result in a pressure rise above Pbase during inspiration and will drop below Pbase during exhalation. When patient flow is near zero (i.e., at the beginning and end of inspiration, as well as the beginning and end of exhalation) the output pressure approaches P_(base).

With different gain settings, any number of wave forms can be generated. For example, a high setting may be established for Gain_(Insp) and a low setting for Gain_(Exp), or vice versa, or the gain settings for inspiratory flow and expiratory flow may be the same.

PPAP therapy seeks to provide only the pressure that is necessary to prevent airway collapse at any given moment during the breathing cycle. This will generally result in supplying, at appropriate times, maximum pressure only when peak negative airway inspiratory pressures are detected and minimum pressure only when peak positive airway exhalation pressures are detected. At all other times during the breathing cycle, the PPAP apparatus delivers air at a variable pressure responsive to the patient's respiratory efforts in a range between the maximum and minimum pressures. As mentioned above, PPAP therapy also involves the administration of a base pressure of zero or greater to which the product of a selected gain times instantaneous flow (inspiratory and expiratory) is continuously added to produce the instantaneous output pressure of the PPAP apparatus. An identical gain may be selected for inspiration and expiration, or different gain values may be independently selected for inspiration and expiration. The base pressure will be the pressure necessary to overcome any mechanical collapsing forces that result from the structure of the airway tissues, muscle tone, and body position. In other words, the base pressure will be equivalent to the expiratory positive airway pressure of "EPAP" typically used in bi-level PAP therapy.

According to the present invention, PPAP therapy thus represents a novel respiratory disorder treatment by which patient comfort (and, therefore, treatment compliance) exceed that offered by either CPAP or bi-level PAP therapy.

Similar to PPAP therapy's use for preventing airway collapse, PPAP therapy for the treatment of CHF delivers only the minimum amount of pressure needed to reduce cardiac preload and afterload. This will result in supplying a base pressure to the exterior of the heart equivalent to the pressure needed to reduce cardiac preload and afterload in the absence of respiratory loading and a varying pressure which is needed to overcome the impact of respiratory loading on cardiac preload and afterload while minimizing the work of breathing.

Supplying positive pressure to the exterior of the heart via the respiratory system has two benefits firstly, the positive pressure will reduce the enlarged heart of a CHF patient to a size closer to normal. This return to normal size, allows the muscles of the heart to work more effectively. Secondarily, the positive pressure in the chest cavity reduces the amount of pressure the heart must overcome to pump blood to the rest of the body.

The heart and chest cavity are at the same pressure. Typically this pressure fluctuates about ambient pressure due to the impact of respiratory loading. The circulatory system has a working pressure that varies as the heart pumps but averages 100 mm HG in normal-tensive patients. The heart must supply the power to force blood from the chest cavity into the pressurized circulatory system. Increasing the pressure in the chest cavity reduces the amount of pressure the heart must over come to pump blood. A pressure in the chest cavity of 10 cm H₂ O or approximately 10 mm Hg will reduce the load on the heart by 10 mm Hg/100 mm Hg or roughly 10%.

The impact of respiratory effort on the heart is as follows:

During inspiration, the pressure in the chest (and thus surrounding the heart) becomes more negative relative to the rest of the body. This increased negative pressure increases the amount of pressure the heart must generate to pump blood from the chest cavity to the body. By providing pressure in excess of the base pressure during inspiration, PPAP is able to offset this decrease in chest cavity pressure and maintain a relatively constant pressure in the chest.

During exhalation the pressure in the chest becomes less negative relative to the rest of the body. By reducing the pressure during exhalation, PPAP is able to offset the increase in chest cavity pressure and maintain a relatively constant pressure in the chest.

By minimizing the decrease in pressure and taking advantage of the increased pressure during exhalation, the variable portion of PPAP allows a lower baseline to be set relative to using a constant pressure with the same benefits to the heart. This lower baseline and reduced pressure during exhalation also reduces the work of breathing and increases patient comfort.

Other details, objects and advantages of the present invention will become apparent as the following description of the presently preferred embodiments and presently preferred methods of practicing the invention proceeds.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention will become more readily apparent from the following description of preferred embodiments therefor shown, by way of example only, in the accompanying drawings, wherein:

FIG. 1 is a functional block diagram of an apparatus according to the instant invention;

FIG. 2 is a functional block diagram of a further embodiment of an apparatus according to the instant invention;

FIG. 3 is a combined pressure and flow diagram graphically representing the general manner in which an apparatus according to the instant invention outputs pressurized breathing gas in proportional relation to patient flow in both the inspiratory and expiratory phases of a single respiratory cycle;

FIG. 4 is a combined pressure and flow diagram similar to FIG. 3 exemplifying a number of apparatus output pressure curves that may be achieved through selective adjustment of inspiratory and expiratory gain setting controls of the proportional positive airway pressure circuitry of the instant invention;

FIG. 5 is a combined pressure and flow diagram similar to FIG. 3 contrasting a pressure output curve typical of an apparatus according to the instant invention with pressure output curves of conventional respiratory assistance apparatus;

FIG. 6 is a combined pressure and flow diagram similar to FIG. 3 depicting alternative pressure profiles that may be employed at the beginning of an inspiratory phase of respiration to facilitate the onset of inspiration;

FIG. 7 is a combined pressure and flow diagram similar to FIG. 3 illustrating a resultant apparatus pressure output curve that may be achieved through combination of conventional continuous positive airway pressure therapy with proportional positive airway pressure therapy according to the instant invention;

FIG. 8 is a combined pressure and flow diagram similar to FIG. 3 showing a resultant apparatus pressure output curve that may be effected through combination of conventional bi-level positive airway pressure therapy with proportional positive airway pressure therapy according to the instant invention;

FIG. 9 is a combined pressure and flow diagram similar to FIG. 3 reflecting a further resultant apparatus pressure output curve that may be achieved through combination of conventional bi-level positive airway pressure therapy with proportional positive airway pressure therapy according to the instant invention; and

FIG. 10 is a functional block diagram of a further embodiment of an apparatus according to the instant invention.

DETAILED DESCRIPTION OF THE INVENTION

There is generally indicated at 10 in FIG. 1 a proportional positive airway pressure (PPAP) apparatus according to a presently preferred embodiment of the instant invention and shown in the form of a functional block diagram. Apparatus 10 is operable according to a novel process, which is another aspect of the instant invention, to deliver breathing gas such as air, oxygen or a mixture thereof at relatively higher and lower pressures (i.e., generally equal to or above ambient atmospheric pressure) to a patient 12 in proportion to the patient's respiratory flow for treatment of Obstructive Sleep Apnea Syndrome (OSAS), Chronic Obstructive Pulmonary Disorder (COPD) and other respiratory disorders.

Apparatus 10 comprises a gas flow generator 14 such as a conventional CPAP or bi-level PAP blower (i.e., a centrifugal blower with a relatively steep pressure-flow relationship at any constant speed) which receives breathing gas from any suitable source, e.g., a pressurized bottle 16 of oxygen or air, the ambient atmosphere, or a combination thereof. The gas flow from flow generator 14 is passed via a delivery conduit means 18 to a breathing appliance or patient interface 20 of any suitable known construction which is worn by patient 12. The conduit means 18 may include a large bore flexible tube and the patient interface 20 may preferably be a nasal mask or a full face mask as shown. Other breathing appliances which may be used in lieu of a mask include a mouthpiece, a nasal seal, nasal prongs or cannulae, an endotracheal tube, a trachea adapter or any other suitable appliance for interfacing between a source of breathing gas and a patient.

The apparatus also includes a sensor means such as a flow transducer 22 or similar flow sensing element situated within or near the breathing circuit, i.e., the patient interface 20, conduit means 18 or gas flow generator 14. Flow transducer 22 may comprise any suitable gas flow meter such as, for example, a bidirectional dynamic mass flow sensor. Preferably, however, the flow transducer is a pressure responsive sensor for detecting the magnitude of the pressure gradients between the inlet of the patient's airway and his lungs (within the scope of the present invention, flow and respiratory pressure gradient are highly correlated). In accordance with a presently preferred embodiment, the flow transducer 22 is interposed in line with conduit means 18, most preferably downstream of a pressure controller 24. The flow transducer generates output signals that are fed, as indicated by reference numeral 26, to proportional positive airway pressure (PPAP) circuitry 28 to be described in greater detail hereinafter. The output signals include first flow rate signals indicative of inspiration by the patient and second flow rate signals indicative of the patients expiration. The signals are continuously transmitted and correspond to the instantaneous flow rate of breathing gas within conduct means 18.

In addition, the output from flow transducer 22 is also desirably fed, as indicated by reference numeral 30, to an optional leak computer 32. A suitable leak computer for present purposes is that disclosed in U.S. Pat. No. 5,148,802 (the disclosure of which is incorporated herein by reference) although other means for substantially instantaneously calculating system leakage, including both known leakage such as that discharged through a mask exhaust port 34, and unknown leakage such as that at various conduit couplings or at the patient contact site of the patient interface 20, would be acceptable. With any non-invasive embodiment of the present invention (i.e., not involving an endotracheal tube or trachea adapter), the patient flow must be estimated taking into account the aforesaid known and unknown system leaks.

The output signal from the leak computer 32 is fed, as at 36, to the PPAP circuitry 28. In this way, the PPAP circuitry logic may continuously compare the output from the flow transducer 22 with that from the leak computer 32 to thereby discriminate that portion of system flow which is associated with the patient's respiration from that caused by system leakage. As a result, the PPAP circuitry 28 may more precisely control the output of the pressure controller 24 as a function of patient respiratory flow rather than overall system flow.

If formed as a mask, as illustrated, the patient interface 20 commonly includes, as mentioned above, a suitable exhaust port means, schematically indicated at 34, for exhaust of breathing gases during expiration. Exhaust port means 34 preferably is a continuously open port which imposes a suitable flow resistance upon exhaust gas flow to permit the pressure controller 24, located in line with conduit means 18 between flow generator 14 and the patient interface 20, to control the pressure of air flow within conduit means and thus within the airway of the patient 12. For example, exhaust port 34 may be of sufficient cross-sectional flow area to sustain a continuous exhaust flow of approximately 15 liters per minute at a system pressure of 10 cm H₂ O. The flow via exhaust port 34 is one component, and, typically, the major component of the overall system leakage, which is an important parameter of system operation. In an alternative embodiment, it has been found that a non-rebreathing valve may be substituted for the continuously open port 34.

The pressure controller 24 is operative to control the pressure of breathing gas within the conduit means 18 and thus within the airway of the patient. Pressure controller 24 is located preferably, although not necessarily, downstream of flow generator 14 and may take the form of an adjustable, electronically-controlled valve.

Apparatus 10 also desirably includes a safety circuit, preferably comprising an adjustable maximum pressure setting control 38 and an adjustable minimum pressure setting control 40 operatively connected to pressure controller 24. The safety circuit allows the manufacturer, the patient or his overseeing health care professional to selectively establish minimum and maximum system output pressures below and above which the system will not dispense pressurized gas. The minimum pressure will, of course, be at least zero and, preferably, a threshold pressure sufficient to maintain pharyngeal patency during expiration. The maximum pressure, on the other hand, will be a pressure somewhat less than that which would result in over-inflation and perhaps rupture of the patient's lungs. The safety circuit functions differently than the pressure controls which determine, for instance, the CPAP prescription pressure or the IPAP and EPAP prescription pressures used in bi-level PAP therapy. That is, instead of establishing lower and upper prescription pressures to be administered during normal usage of the apparatus (subject to the influence of the PPAP circuitry 28), the maximum and minimum pressure setting controls 38 and 40 set absolute minimum and maximum fail-safe output pressure limits which are not to be exceeded. Thus, the danger of potential physical harm to the patient in the even of malfunction of other system components, e.g., the prescription pressure controls, is effectively eliminated.

The PPAP circuitry 28 according to the present invention is subject to the influence of additional essential controls, including a base pressure control 42, an inspiratory gain setting control 44 and an expiratory gain setting control 46. The base pressure control 42 establishes a base pressure (P_(base)), usually greater than or equal to zero and conceptually equal to the EPAP level in bi-level therapy, sufficient to maintain airway patency at the beginning and end of exhalation. The inspiratory gain setting control 44 permits selection of a resistive gain (Gain_(Insp)) to be applied to the detected inspiratory flow. Similarly, the expiratory gain setting control 46 enables selection of a resistive gain (Gain_(Insp)) to be applied to the detected expiratory flow.

In a broad sense, PPAP therapy and the PPAP apparatus 10 constitute a novel system providing pressure to a patient via nasal, nasal/oral, oral, or trachea interface to treat OSAS, COPD and other breathing disorders. The pressure delivered to the patient is a function of the patient flow rate. The function can be described as follows.

    P.sub.delivered =P.sub.base +Gain*Flow

Where:

"P_(delivered) " is the pressure delivered to the patient interface.

"P_(base) " is the base line pressure (greater than or equal to zero and conceptually equal to EPAP).

"Flow" is the estimated patient flow rate determined by the flow transducer.

"Gain" is the constant used to augment pressure based on the flow rate. The gain constant can further be refined to allow one constant for inspiration (positive flow) and a different constant for exhalation (negative flow).

FIG. 3 represents a combined pressure and flow diagram graphically depicting the manner in which apparatus 10 outputs pressurized breathing gas in proportional relation to patient flow (as detected by flow transducer 22) in both the inspiratory and expiratory phases of a respiratory cycle. The pressure curve of FIG. 3, however, reflects a situation where the same gain is chosen for both inspiratory and expiratory flow. Conceivably, essentially the same pressure curve may be generated by the apparatus disclosed in the aforementioned essay entitled "An Apparatus for Altering the Mechanical Load of the Respiratory System," by Younes, et al. which may use a single resistive gain applicable to both inspiration and expiration.

With PPAP apparatus 10, however, separate and independent gains may be chosen for inspiration and expiration, whereby gains best suited to optimizing performance, i.e., minimizing breathing work, may be precisely matched with each of the inspiratory and expiratory phases. Thus, the function of the apparatus described in the Younes et al. article corresponds to a special and relatively limited application of the present invention where the selected inspiratory and expiratory gains are identical. As is far more often the case, however, an optimum inspiratory gain is not the optimum expiratory gain and vice versa. Thus, the pressure output of the PPAP apparatus 10 is more accurately described according to the following functions, which functions can be encoded into the PPAP circuitry 28.

    P.sub.inhalation =P.sub.base +Gain.sub.Insp *Flow

and

    P.sub.exhalation =P.sub.base +Gain.sub.Exp *Flow

Where:

"Gain_(Insp) " is the constant used during inspiration (positive flow) to boost pressure based on the flow rate.

"Gain_(Exp) " is the constant used during exhalation (negative flow) to reduce pressure based on the flow rate.

The gain typically selected has a range of about 0 to 10 cm H₂ O/liter/second for inspiration. The gain chosen for exhalation is normally lower than the inspiratory gain (e.g., values in the range of 0 to 4 cm H₂ O/liter/second), although higher gain values may be chosen for inspiration and/or expiration, if such is desired or necessary.

Regardless of the chosen gain values, applying a flow signal derived from a normal respiratory pattern will result in a pressure rise above P_(base) during inspiration and will drop below P_(base) during exhalation. When patient flow is near zero (i.e., at the beginning and end of inspiration, as well as the beginning and end of exhalation) the output pressure approaches P_(base).

FIG. 4 perhaps most clearly exemplifies the effect that the selection of different gains for both the inspiratory and expiratory phases of a respiratory cycle has upon the pressure output curve. Gain_(Insp)(a), Gain_(Insp)(b), Gain_(Insp)(c) and Gain_(Insp)(d) represent, in descending order, several of an infinite range of gain values that may be applied during inspiration. Similarly, Gain_(Exp)(e), Gain_(Exp)(f), Gain_(Exp)(g) and Gain_(Exp)(h) indicate increasing expiratory gain values. With different gain settings, therefore, any number of wave forms can be generated. For example, a high setting may be established for Gain_(Insp) and a low setting for Gain_(Exp), or vice versa, or the gain settings for inspiratory flow and expiratory flow may be the same.

PPAP therapy seeks to provide only the pressure that is necessary to prevent airway collapse at any given moment during the breathing cycle. This will generally result in supplying, at appropriate times, maximum pressure only when peak negative airway inspiratory pressures are detected and minimum pressure only when peak positive airway exhalation pressures are detected. At all other times during the breathing cycle, the PPAP apparatus delivers air at a variable pressure responsive to the patient's respiratory efforts in a range between the maximum and minimum pressures. As mentioned above, PPAP therapy also involves the administration of a base pressure of zero or greater to which the product of a selected gain times instantaneous flow (inspiratory and expiratory) is continuously added to produce the instantaneous output pressure of the PPAP apparatus. An identical gain may be selected for inspiration and expiration, or different gain values may be independently selected for inspiration and expiration. The base pressure will be the pressure necessary to overcome any mechanical collapsing forces that result from the structure of the airway tissues, muscle tone, and body position. In other words, the base pressure is generally equivalent to the expiratory positive airway pressure or "EPAP" typically used in bi-level PPAP therapy.

In this connection, FIG. 5 illustrates the pressure output curve generated by the PPAP apparatus 10 vis-a-vis conventional CPAP and bi-level PAP apparatus over a single respiratory cycle. So long as the appropriate inspiratory and expiratory splint pressures are applied at point 48 (peak inspiratory flow), point 50 (beginning of exhalation) and point 52 (end of exhalation), less pressure may be provided at all other times during the breathing cycle than is normally supplied by conventional bi-level PAP therapy. This reduced output pressure is represented by the "PPAP" curve of FIG. 5. The hatched areas of that figure reflect the difference in pressures provided by PPAP and the IPAP and EPAP phases of bi-level PAP during a typical respiratory cycle. The hatched areas may be conceptualized as the respiratory work or effort savings which are attributable to PPAP. This work savings, as would be expected, translates to greater comfort for the PPAP assisted patient and increased compliance with the respiratory treatment.

Referring again to FIG. 1, it will thus be appreciated that the pressure controller 24 is continuously governed by and outputs variable pressure responsive to a command signal 54 from PPAP circuitry 28. Command signal 54, in turn, is the product of the influences of one or more of the outputs from the flow transducer 22, leak computer 32, base pressure control 42, inspiratory gain setting control 44, expiratory gain setting control and, perhaps, a pressure profile control 56 discussed below.

In normal breathing, a negative pressure gradient must be generated before flow can begin. Hence, the negative pressure waveform generated in the airway must precede and thereby induce inspiratory flow at the start of inspiration. In an unstable airway, which is characteristic of OSAS, for example, this asynchronous relationship of negative pressure gradient and inspiratory flow onset would, if not accommodated by suitable compensatory measures, lead to a situation where the PPAP therapy would not generate sufficient pressure (due to low flow) to overcome the negative pressure in the airway, whereby total or partial airway collapse may result. This problem can be solved by a number of methods. For instance, a higher PPAP base pressure can be used to provide additional pressure to support the airway at the beginning of inspiration. Alternatively, however, as demonstrated by FIG. 6, a temporary pressure increase can be added at the start of inspiration to support to the airway until sufficient flow is generated to drive the PPAP process. The present invention offers several viable approaches by means of which pressure can be added during the initial phase of inspiration to support the airway as inspiratory flow increases.

Temporary pressure increases may be effected using the pressure profile control 56 in operative connection with PPAP circuitry 28 to select a desired elevated pressure waveform in the early stages of inspiration. In this regard, pressure profiles may be used as minimum values for the output pressure at the outset of inspiration, thereby giving rise to the following alternative equations for available output pressure during inspiration.

P_(inhalation) =greater of:

    P.sub.base +Gain.sub.Insp *Flow

or

    P.sub.base +P.sub.profile

Where:

"P_(inhalation) " is the pressure delivered to the patient interface during inspiration "P_(base) " is the base line pressure (conceptually equal to EPAP).

"Flow" is the estimated patient flow.

"Gain_(Insp) " is the constant used during inspiration (positive flow) to boost pressure based on the flow rate.

"P_(profile) " is a function that generates a pressure profile to support the airway at the start of inspiration. Such pressure profile functions may be constant (e.g., a step profile, numeral 58 in FIG. 6), time based (for instance, a backwards ramp profile, numeral 60 in FIG. 6), or any other functional shape.

Alternatively, pressure profiles can be used exclusively to control the output pressure for a predetermined initial segment of inspiration. The following equations represent system output pressure during inspiration under such control conditions.

    P.sub.inhalation =P.sub.profile from start of breath to X

and

    P.sub.inhalation =P.sub.base +Gain.sub.Insp * Flow from X to start of exhalation

Where:

"P_(inhalation) " is the pressure delivered to the patient interface during inspiration.

"P_(base) " is the base line pressure (conceptually equal to EPAP).

"Flow" is the estimated patient flow.

"Gain_(Insp) " is the constant used during inspiration (positive flow) to boost pressure based on the flow rate.

"P_(profile) " is any function that generates a pressure profile to support the airway at the start of inspiration. Such functions could be constant (as, for example, a step profile), or time based such as a backwards ramp profile), or any other functional shape.

"X" is a preselected transition point determined by time, or analysis of the flow signal (such as curvature, percent drop from peak flow rate, integration, derivative, analysis of prior breaths or a combination of flow analysis and time).

The PPAP apparatus 10 also has the capacity to measure and store in a memory 62 (FIG. 1) the following parameters: tidal volume, inspiratory time, expiratory time, peak pressure, peak flow, O₂ saturation (as a voltage input from an external source), plural pressure (as a voltage input from an outside source), mask pressure, estimated leakage, and system parameters (P_(base), AutoGain_(Insp), Gain_(Insp), Gain_(exp), IPAP and EPAP).

A further method by means of which the instant system addresses the problem presented by the changing needs of the patient is to combine the beneficial features of PPAP with a more controlled therapy such as CPAP, as is shown in FIG. 7.

With CPAP, a single pressure is generated and delivered throughout the sleeping session. PPAP can be advantageously joined with CPAP to lower pressure during exhalation. The resulting equations for pressure delivered under combined PPAP-CPAP are as follows:

    P.sub.inhalation =CPAP

and

    P.sub.exhalation =CPAP+Gain.sub.Exp *Flow

Where:

"Gain_(Exp) " is the constant used during exhalation (negative flow) to reduce pressure based on the flow rate.

FIG. 8 demonstrates that PPAP can also be combined with bi-level PAP therapy in a number of ways to produce effective therapeutic pressure wave forms. One application, generally similar to the aforementioned PPAP-CPAP scenario, is to use PPAP to lower the pressure during exhalation. The resulting equations for the delivery of composite PPAP-bi-level PAP pressure are as follows:

    P.sub.inhalation =IPAP

and

    P.sub.exhalation =EPAP+Gain.sub.Exp *Flow

Where:

"Gain_(Exp) " is the constant used during exhalation (negative flow) to reduce pressure based on the flow rate.

Another approach to merging PPAP with bi-level therapy is shown in FIG. 9 wherein IPAP for the first portion of inspiration and PPAP for the remainder of the breathing cycle. Gain_(Insp) would be automatically calculated for each breath based on IPAP and the flow rate as follows:

    P.sub.inhalation (t.sub.0 to t.sub.1)=IPAP

and

    P.sub.inhalation (t.sub.1 to t.sub.2)=P.sub.base +AutoGain.sub.insp *Flow

and

    P.sub.exhalation =P.sub.base +Gain.sub.Exp *Flow

Where:

"Flow" is the estimated flow rate.

"t₀ " is the time at the start of breath.

"t₁ " is the time when the estimated flow rate is a predetermined percentage of peak inspiratory flow rate.

"t₂ " is the time at the start of exhalation.

"IPAP" is a continuously applied inspiratory positive airway pressure.

"P_(inhalation) (t₀ to t₁)" is the pressure delivered to the patent from t₀ to t₁.

"P_(base) " is a continuous base pressure.

"AutoGain_(Insp) " equals (IPAP-P_(base))/Flow at t₁.

"P_(inhalation) " (t₁ to t₂) is the pressure delivered to the patient from t₁ to t₂.

"Gain_(Exp) " is the constant used during exhalation to reduce pressure delivered to the patient.

"P_(exhalation) " is the pressure delivered to the patient during exhalation.

It is to be understood that the flow and PPAP pressure output curves of FIGS. 3 through 9 represent the apparatus output pressure and flow during the inspiratory and expiratory phases of a single respiratory cycle. The PPAP and flow curves can, of course, be expected to vary somewhat from respiratory cycle to respiratory cycle depending on the patient's respiratory requirements, particularly under fully automated PPAP therapy described hereinafter. Furthermore, somewhat greater variations will likely occur between the respiratory cycles associated with different stages of an extended treatment session (especially during OSAS treatment).

FIG. 2 represents a further preferred embodiment of a PPAP apparatus pursuant to the present invention, designated herein by reference numeral 10'. Apart from the addition IPAP/EPAP (bi-level PPAP) circuitry 64, PPAP apparatus 10' is identical in structure and function to PPAP apparatus 10. According to this embodiment, output 66 from flow transducer 22 is fed to bi-level PAP circuitry 64. Bi-level PAP circuitry 64 may assume any conventional form such as, for example, that described in U.S. Pat. No. 5,148,802. The output 68 from the bi-level PPAP circuitry is transmitted to the PPAP circuitry 28, which output consists of an IPAP signal should the patient be inhaling or an EPAP signal in the event the patient is exhaling. The logic of the PPAP circuitry 28 may then utilize this input according to a preselected one any of the aforementioned combinations of PPAP-bi-level therapy to generate a desired pressure command signal 54.

Pursuant to the present invention, the pressure delivered to the patient is determined by the base pressure, the flow rate and the gain (and the pressure profile if used). For a given patient condition, these settings can be adjusted as necessary to stabilize the airway. In OSAS a patient's periodic and, to a lesser extent, instantaneous condition is variable with sleep state and body position. Thus, settings that may work well in during one portion of a sleeping session may not work as well at a different time. In other words, settings that support the airway at its most unstable state may cause pressures that are higher than necessary during more stable times. Likewise, settings that work well at one point in the session may be insufficient at another time.

The present invention proposes several methods to minimize the impact of the patient's changing needs on the optimization of PPAP therapy. One such method is to automatically adjust the gain, pressure profile and baseline pressure to meet the patient's demands. This adjustment can be based on analysis of patient parameters related to flow (e.g., magnitude, shape, derivative, integral (volume), pressure , snoring, arterial oxygen saturation, exhaled CO₂, airway diameter, or other parameters).

Using one or more of these parameters the system may adjust the Gain_(Insp) to prevent partial airway obstruction (hypopnea). The goal of such systems is to increase Gain_(Insp) responsive to any of the following patient conditions:

decreased inspiratory flow

decreased inspiratory volume

increased airway resistance (as determined by flow or pressure signal analysis)

airway instability (as indicated by pressure or sound variations)

drops in arterial oxygen saturation

decreases in airway diameter

The apparatus according to the invention may also maintain minimal Gain_(Insp) in the absence of these conditions.

The present system may also adjust the base pressure (P_(base)) to prevent complete collapse of the airway (apnea) or severe collapse (severe hypopnea). Apnea can be detected by analysis of the flow signal and/or by using reflected pressure waves, or a combination of pressure and flow to determine airway patency. Moreover, it may be important to determine if the apnea is caused by airway collapse or by a lack of respiratory drive. If an obstructive event is detected the base pressure can therefore be increased to open the airway. A further capability of the present system is to maintain a minimum P_(base) in the absence of these conditions.

The system may also adjust the pressure profile (P_(profile)) to prevent apnea or hypopnea at the onset of inspiration. As such, the system may increase P_(profile) in response to decreased inspiratory flow, decreased respiratory volume, flow waveform shape analysis that indicates increasing airway resistance, pressure or sound variations indicative of airway instability, drops in arterial oxygen saturation, decreases in airway diameter or a change in exhaled CO₂. Commensurate, therewith, the present invention also functions maintain the minimum pressure profile in the absence of these conditions.

FIG. 10 reveals a presently preferred embodiment of a fully automated PPAP apparatus 10" constructed according to the present invention. Generally similar in structure and function to PPAP apparatus 10 of FIG. 1, PPAP apparatus 10" additionally incorporates a microprocesser or central processing unit (CPU) 70 which preferably utilizes an output signal 72 from flow transducer 28 as a continuous feedback signal to enable the CPU to continuously adjust P_(base), P_(profile) and Gain_(Insp) as necessary. The CPU may, however, be configured to effect its continuous system control functions responsive to any of the aforementioned patient parameters related or unrelated to respiratory flow.

The apparatus 10" also has the capability to detect hypopnea (as evidenced by decreases in peak flow and/or tidal volume for a given period of time) and the occurrence of apneas (as manifested by very little flow for a given period of time). To detect hypopnea, for example, the CPU 70 may be programmed to make a comparison between a short term average of peak inspiratory flow rate or tidal volume (e.g., a 3 breath average) and a long term average of peak flow rate or tidal volume (e.g., greater than 20 breaths). If a decrease of greater than 25% is detected the system determines a hypopnea to be present. This determination is desirably made only if the leakage is well estimated and stable. Thus, large changes in leak or initiation of a leak recovery will cause data to be ignored.

The invention further includes a method for determining if the airway is open (central apnea) or obstructed (obstructive apnea) during an apnea. Once an apnea of significant duration is detected the system, under the direction of CPU 70, automatically increases Gain_(Insp) by 2 cm H₂ O , waits approximately 1 second and decreases the pressure back to the original value. If there is a significant change in flow during this pressure change, the system concludes that the airway is open (central apnea). If there is no significant change in flow the system determines that the airway is obstructed (obstructive apnea). The system will continue to monitor each apnea for its entire duration at periodic intervals to determine the nature of the apnea.

In accordance with a preferred embodiment, the PPAP apparatus 10" controls are automatically adjusted as follows. In the event of a hypopnea, Gain_(Insp) is increased by 2 cm/liter/second. In the event of an obstructive apnea, P_(base) is increased by 1 cm H₂ O. The device will continue to increase P_(base) as long as an obstructive apnea of significant duration is detected. The device will not increase Gain_(Insp) again, if necessary, until 5 breaths have passed. If no hypopnea or apneas occur over a period of 30 breaths, Gain_(Insp) is decreased by 1 cm/liter/second. If no hypopnea or apneas occur over a period of 50 breaths, P_(base) is decreased by 1 cm H₂ O. In addition, the apparatus may control the delivery of O₂ while patient flow is greater than zero, if such desired or necessary.

Although not illustrated, still further embodiments of the present invention contemplate the incorporation of fully automated PPAP with CPAP and/or bi-level PAP therapy. In these cases CPAP or IPAP may be controlled using the same logic that controls Gain_(Insp) in the above-described fully automated PPAP system. Likewise, P_(base) may be controlled in a similar manner to that described in connection with fully automated PPAP.

The fully automated PPAP-CPAP or PPAP-bi-level PAP systems may also adjust P_(profile) to prevent apnea or hypopnea at the start of inspiration. Such systems may therefore increase CPAP (or IPAP) or P_(profile) in the face any of the following patient conditions:

decreased inspiratory flow

decreased inspiratory volume

increased airway resistance (as determined by flow or pressure signal analysis)

airway instability (as indicated by pressure or sound variations)

drops in arterial oxygen saturation

decreases in airway diameter

It will be understood that CPAP or IPAP would be maintained at minimal levels in the absence of these conditions.

Using PPAP therapy, therefore, it is additionally possible to employ PPAP in response to expiratory flow to reduce pressure applied during expiration to less than the patient's PEEP level throughout all but the end of the expiratory phase in a manner similar to that described for lowering the pressure below P_(base) during exhalation in the treatment of OSAS. This lowering of applied pressure to less than PEEP during the expiratory phase diminishes breathing work and enhances patient comfort when compared to the constant expiratory phase pressure applied during EPAP. Indeed, PPAP can be adapted to any ventilation mode that uses PEEP. Such applications may include pressure support with PEEP, PAV with PEEP or other applications of PEEP in respiratory assistance therapy.

Furthermore, the administration of oxygen in phase with inspiration may also easily be included with PPAP therapy for the treatment of COPD patients requiring supplemental oxygen.

When using PPAP to treat CHF, one can reduce mean pressure and work of exhalation while still providing the same level of rest to the heart. By applying a positive base pressure substantially equivalent to a pressure needed to reduce cardiac preload and afterload (preferably in the range of 5-10 cm H₂ O), one can help the heart reduce its efforts. With additional positive pressure during inspiration in proportion to respiratory effort, one can overcome the effect of negative pressure being produced during inspiration. PPAP is particularly appropriate in CHF patients in that the typical CHF patient has normal lung compliance. In these patients much of the respiratory loading can be inferred from the flow signal. By reducing the pressure below the base pressure during exhalation, one can reduce the work of exhalation without reducing the benefit to the heart. The net effect will be the same benefit to the heart with reduced work of breathing and lower mean pressure.

Although the invention has been described in detail for the purpose of illustration, it is to be understood that such detail is solely for that purpose and that variations can be made therein by those skilled in the art without departing from the spirit and scope of the invention except as it may be limited by the claims. 

What is claimed is:
 1. A Proportional Positive Airway Pressure apparatus for delivering pressurized breathing gas to the airway of a patient, said apparatus comprising:means for continuously delivering breathing gas at a minimally sufficient pressure to reduce cardiac preload and afterload at any given moment during at least a portion of a breathing cycle where the minimally sufficient gas pressure may continuously vary during the at least a portion of a breathing cycle and is responsive to a sensed rate of flow of gas, said minimally sufficient gas pressure being the summation of a pressure needed to reduce cardiac preload and afterload in the absence of respiratory loading and a pressure needed to overcome the impact of respiratory loading on cardiac preload and afterload, gas flow generator means for providing a source of gas; conduit means for delivering gas to the airway of a patient from said source of gas; circuitry means for providing a command signal to regulate a pressure controller means; sensor means for continuously detecting the rate of flow of gas within said conduit means and for continuously transmitting signals to said circuitry means corresponding to said rate of flow of gas within said conduit means; first control means operatively connected to said circuitry means for selectively establishing a first gain to be applied by said circuitry means to first flow rate signals continuously transmitted by said sensor means to said circuitry means, said first flow rate signals corresponding to flow within said conduit means indicative of inspiration; second control means operatively connected to said circuitry means for selectively establishing a second gain to be applied by said circuitry means to second flow rate signals continuously transmitted by said sensor means to said circuitry means, said second flow rate signals corresponding to flow within said conduit means indicative of expiration, and pressure controller means co-operable with said gas flow generator means for delivering said gas flow within said conduit means and within the airway of a patient at said minimally sufficient gas pressure during the at least a portion of a breathing cycle in proportion to both said first gain and said continuously transmitted first flow rate signals during inspiration and in proportion to both said second gain and said continuously transmitted second flow rate signals throughout expiration in response to said command signal.
 2. The apparatus of claim 1 further comprising means operatively connected to said circuitry means for selectively establishing a base pressure to be provided by said pressure controller means, said base pressure being provided by said pressure controller means in addition to said gas pressure provided in proportion to said first gain and said first flow rate signals during inspiration and in proportion to said second gain and said second flow rate signals throughout expiration, said base pressure being substantially equivalent to said pressure needed to reduce cardiac preload and afterload in the absence of cardiac loading, and said pressure needed to overcome respiratory loading being proportional to the respective gain.
 3. The apparatus of claim 2 further comprising means operatively connected to said circuitry means for selectively establishing an elevated pressure profile to be provided by said pressure controller means during a predetermined initial segment of inspiration.
 4. The apparatus of claim 2 further comprising means in signal receiving communication with said sensor means and operatively connected to said first control means and said means for selectively establishing a base pressure for substantially continuously adjusting at least one of said first gain and said base pressure responsive to signals received from said sensor means.
 5. The apparatus of claim 3 further comprising means in signal receiving communication with said sensor means and operatively connected to said first control means, said means for selectively establishing a base pressure and said means for selectively establishing an elevated pressure profile for substantially continuously adjusting at least one of said first gain, said base pressure and said elevated pressure profile responsive to signals received from said sensor means.
 6. The apparatus of claim 1 further comprising means operatively connected to said circuitry means for selectively establishing an elevated pressure profile to be provided by said pressure controller means during a predetermined initial segment of inspiration.
 7. The apparatus of claim 1 further comprising means operatively connected to said pressure controller means for preventing said pressure controller means from providing said flow of gas above a predetermined maximum pressure.
 8. The apparatus of claim 1 further comprising means operatively connected to said pressure controller means for preventing said pressure controller means from providing said flow of gas below a predetermined minimum pressure.
 9. The apparatus of claim 1 further comprising memory means operatively connected to said circuitry means for measuring and storing information associated with operation of said apparatus.
 10. The apparatus of claim 1 further comprising means in signal receiving communication with said sensor means and operatively connected to said circuitry means for substantially instantaneously calculating gas leakage from said apparatus responsive to signals received from said sensor means.
 11. The apparatus of claim 1 further comprising means in signal receiving communication with said sensor means and operatively connected to said first control means for substantially continuously adjusting said first gain responsive to signals received from said sensor means.
 12. The apparatus of claim 1 further comprising means in signal receiving communication with said sensor means and operatively connected to said circuitry means for transmitting to said circuitry means an inspiratory positive airway pressure signal responsive to said first flow rate signals received from said sensor means and an expiratory positive airway pressure signal responsive to said second flow rate signals received from said sensor means.
 13. A method of providing Proportional Positive Airway Pressure to the airway of a patient, said method comprising the steps of:providing means for continuously delivering breathing gas at a minimally sufficient pressure to reduce cardiac preload and afterload at any given moment during at least a portion of a breathing cycle where the minimally sufficient gas pressure may continuously vary during the at least a portion of a breathing cycle and is responsive to a sensed rate of flow of gas, said minimally sufficient gas pressure being the summation of a pressure needed to reduce cardiac preload and afterload in the absence of respiratory loading and a pressure needed to overcome the impact of respiratory loading on cardiac preload and afterload, providing a source of gas; supplying gas to the airway of a patient from said source of gas; substantially continuously determining the flow rate of gas between said source and the airway of a patient; applying a first gain to a determined flow rate of gas indicative of inspiration; applying a second gain to a determined flow rate of gas indicative of expiration; and delivering said minimally sufficient gas pressure in proportion to said first gain and said determined flow rate during inspiration and in proportion to said second gain and said determined flow rate throughout expiration.
 14. The method of claim 13 further comprising the step of:providing a base pressure of gas in addition to said gas pressure provided in proportion to said first gain and said first flow rate signals during inspiration and in proportion to said second gain and said second flow rate signals throughout expiration, said base pressure being substantially equivalent to said pressure needed to reduce cardiac preload and afterload in the absence of respiratory loading, and said pressure needed to overcome respiratory loading being proportional to the respective gain.
 15. The method of claim 14 further comprising the step of:during inspiration, providing the greater of a selected elevated pressure profile and said gas pressure provided in proportion to said first gain and said first flow rate signals.
 16. The method of claim 14 further comprising the step of:during inspiration, providing a selected elevated pressure profile for a predetermined initial segment of inspiration and providing said gas pressure in proportion to said first gain and said first flow rate signals for the remainder of inspiration.
 17. The method of claim 14 further comprising the step of:substantially continuously adjusting at least one of said first gain and said base pressure responsive to said determined flow rate.
 18. The method of claim 14 further comprising the step of:substantially continuously adjusting at least one of said first gain, said base pressure and a selected elevated pressure profile responsive to said determined flow rate.
 19. The method of claim 13 further comprising the step of:during inspiration, providing the greater of a selected elevated pressure profile and said gas pressure provided in proportion to said first gain and said first flow rate signals.
 20. The method of claim 13 further comprising the step of:during inspiration, providing a selected elevated pressure profile for a predetermined initial segment of inspiration and providing said gas pressure in proportion to said first gain and said first flow rate signals for the remainder of inspiration.
 21. The method of claim 13 further comprising the step of:preventing said gas pressure from being provided above a predetermined maximum pressure.
 22. The method of claim 13 further comprising the step of:preventing said gas pressure from being provided below a predetermined minimum pressure.
 23. The method of claim 13 further comprising the step of:measuring and storing information associated with performance of said method.
 24. The method of claim 13 further comprising the step of:substantially continuously calculating gas leakage responsive to said determined flow rate.
 25. The method of claim 13 further comprising the step of:substantially continuously adjusting said first gain responsive to said determined flow rate.
 26. A method of providing Proportional Positive Airway Pressure to the airway of a patient, said method comprising the steps of:providing means for continuously delivering breathing gas at a minimally sufficient pressure to reduce cardiac preload and afterload at any given moment during expiration where the minimally sufficient gas pressure may continuously vary during expiration and is responsive to a sensed rate of flow of gas, said minimally sufficient gas pressure being the summation of a pressure needed to reduce cardiac preload and afterload in the absence of respiratory loading and a pressure needed to overcome the impact of respiratory loading on cardiac preload and afterload, providing a source of gas; supplying gas to the airway of a patient from said source of gas; substantially continuously determining the flow rate of gas between said source and the airway of a patient; applying a gain to a determined flow rate of gas indicative of expiration; and delivering continuous positive airway pressure during inspiration and said minimally sufficient gas pressure in proportion to said second gain and in proportion to said determined flow rate throughout expiration.
 27. A method of providing Proportional Positive Airway Pressure to the airway of a patient, said method comprising the steps of:providing means for continuously delivering breathing gas at a minimally sufficient pressure to reduce cardiac preload and afterload at any given moment during expiration where the minimally sufficient gas pressure may continuously vary during expiration and is responsive to a sensed rate of flow of gas, said minimally sufficient gas pressure being the summation of a pressure needed to reduce cardiac preload and afterload in the absence of respiratory loading and a pressure needed to overcome the impact of respiratory loading on cardiac preload and afterload, providing a source of gas; supplying gas to the airway of a patient from said source of gas; substantially continuously determining the flow rate of gas between said source and the airway of a patient; applying a gain to a determined flow rate of gas indicative of expiration; and delivering inspiratory positive airway pressure during inspiration and, throughout expiration, providing expiratory positive airway pressure at a lower pressure than said inspiratory positive airway pressure in addition to gas pressure in proportion to said second gain and said determined flow rate.
 28. A method of providing Proportional Positive Airway Pressure to the airway of a patient, said method comprising the steps of:providing means for continuously delivering breathing gas at a minimally sufficient pressure to reduce cardiac preload and afterload at any given moment during a portion (t₁ to t₀) of a breathing cycle where the minimally sufficient gas pressure may continuously vary during the portion of a breathing cycle and is responsive to a sensed rate of flow of gas, said minimally sufficient gas pressure being the summation of a pressure needed to reduce cardiac preload and afterload in the absence of respiratory loading and a pressure needed to overcome the impact of respiratory loading on cardiac preload and afterload, providing a source of gas; supplying gas to the airway of a patient; substantially continuously determining the flow rate of gas between said source and the airway of a patient; and delivering gas pressure to the airway of a patient in accordance with the equations:

    P.sub.inhalation (t.sub.0 to t.sub.1)=IPAP

and

    P.sub.inhalation (t.sub.1 to t.sub.2)=P.sub.base +AutoGain.sub.Insp *Flow at t.sub.1

and

    P.sub.exhalation =P.sub.base +Gain.sub.Exp *Flow,

where Flow is the continuously determined estimated flow rate, t₀ is the time at the start of breath, t₁ is the time when the estimated flow rate is a predetermined percentage of peak inspiratory flow rate, t₂ is the time at start of exhalation, IPAP is a continuously applied inspiratory positive airway pressure, P_(inhalation) (t₀ to t₁) is the pressure delivered to the patient from t₀ to t₁, P_(base) is a continuous base pressure, AutoGain_(Insp) equals (IPAP-P_(base))/Flow at t₁, P_(inhalation) t₁ to t₂ is the pressure delivered to the patient from t₁ to t₂, Gain_(Exp) is the constant used during exhalation to reduce pressure delivered to the patient and P_(exhalation) is the pressure delivered to the patient throughout exhalation. 